Michael Wensing, Marije Bosh, and Richard Grol
Scientific Institute for Quality in Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

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Chronic Heart Failure

• Major variations in treatment repeatedly found
• Use of beta-blockers in primary care ranged from 10% to 50% between countries
• Use of angiotensin-converting enzyme inhibitors (ACE-I) ranged from 50% to 75%
• Differences in national guideline recommendations not sufficient to explain variation
• Comorbidity explained some variation, but 14% of prescriptions related to patient characteristics, not evidence
• Study of barriers to adherence to heart failure guidelines found:
  • Physicians found it difficult to change treatment initiated by cardiologist
  • Titrating the ACE-I dose was seen as difficult
  • Initiating ACE-I in patients already using a diuretic or stable on their current medication was seen as a barrier
• So…how to improve primary care for chronic heart failure and which interventions to select?

Interventions to facilitate uptake of research

• Training for physicians?
• Use of opinion leaders to influence prescribing patterns of cardiologists?
• Providing financial incentives to physicians for each heart failure patient treated according to guideline recommendations?
• Inform the patient and family about appropriate heart failure care?

How to choose an intervention?

• Ideally guided by research evidence on the effectiveness and efficiency of the intervention
• Many KT interventions have not been well-evaluated in rigorous studies
• Available evidence suggests that interventions have variable impact and effect size is moderate
• Current research evidence cannot guide the implementer on the best choice of intervention.
• In addition to “science” we need “art” to choose or design a KT intervention

Professional interventions

• Available evidence focuses mainly on professional interventions (education programs, feedback and reminders)
• Methodological quality is variable but overall is only moderate
• Overall absolute change of professional performance is usually not more than 10%
• Such changes can be clinically or economically relevant

Passive vs active educational interventions

• Passive (written guidelines, lectures and conferences) unlikely to change professional behavior if used alone
• Active (outreach visits and quality circles of professionals) are more likely to induce change
• Active self-study materials or web sites can be effective

Other interventions

• Interventions that bring information close to the point of decision making (reminders, decision support) are likely to be effective
• Patient-directed interventions (preconsultation questionnaires or decision aids) can support quality improvement, but insight into effects on quality of care is limited
• Organizational interventions (revision of professional roles and multidisciplinary teams) can influence clinical outcomes and efficiency – impact on KT is unclear, but improve efficiency and patient satisfaction
• Financial interventions influence volumes of health care use – effect on appropriateness of clinical decisions and practice patterns is unclear

Art of selecting a KT intervention

• Use structured approach to address professionals, patients, teams, organizations and wider systems
• Can include intervention mapping, marketing, proceed/proceed, quality cycle, change management, organizational development, community development, and health technology assessment
• Unclear whether structured approaches result in better knowledge uptake
• Planning models for change propose more or less the same steps or stages, but vary in number

What are the objectives for KT?

• Objectives should be related to outcomes for patients, populations, and society
• Many KT objectives have been defined in terms of specific changes in treatments or other aspects of health care delivery
• Expectation is that changes result in better outcomes
• Often strong research evidence to support this expectation is not available
• Several methods can be used to select objectives, such as a Delphi procedure (Linestone & Turoff 1975)

What are the indicators that can be used to measure implementation?

• Objectives needs to be defined in terms of specific indicators used to measure degree of implementation
• Indicators should have good measurement properties (support from key stakeholders and high feasibility in use)
• Current best practice is a structured Delphi procedure with panels of stakeholders who review available evidence, followed by a test in real practice
• Research of practice variation and quality assessment (chart audits, patient surveys, video observations, and secondary analysis of routine data)

What are potential barriers to change?

• Should analyze barriers to change for each chosen objective:
• Barriers for change as reported by professionals, patients and others – interviews, questionnaires and group methods
• Variation in health care delivery across patients – large observational datasets and statistical methods
• Determinants of effectiveness of KT interventions – longitudinal datasets and advanced quantitative methods

How can we link KT interventions to these barriers?

• Once objectives have been chosen and barriers identified, next step is to link specific KT interventions to the barriers
• Most creative step in the design of KT programs
• Both exploratory and theory-inspired methods can be used
• Exploratory methods try to avoid implicit assumptions – advocate using an “open mind” – often use group brainstorming to identify solutions (live or electronic using Internet platforms)
• Theory used to understand the factors that determine practice variation and change – decision can be taken in a group as well
• Next slides link KT interventions to a number of theory-based factors

Objectives refer to (or target of the intervention)	Barriers for change	Theory	KT interventions (examples)
1. Cognitive factors
Information behavior	Learning style, learning conceptions, innovation adoption behavior, use of communication channels	Cognitive theory on learning (Norman 2002)	Use various information delivery methods or adapt to individual needs
Domain knowledge	Domain knowledge, professional knowledge, complexity of the innovation, intelligence, cognitive competences	Cognitive theory on learning (Norman 2002)	Change the mix of professional skills in the organization
2. Motivational factors
Motivation	Intentional goal setting, stages of change, persuasion	Theory on motivation for learning (Newman & Peile 2002) Theory on stages of change (Prochaska & Velicer 1997) Theory on adopter characteristics (Rogers 1995)	Provide information, social influence, action planning according to needs
Beliefs about consequences	Outcome expectancies, attributions or behavior, impact, centrality, duration of the innovation	Social cognitive theory (Bandura 1986) Theory on innovation characteristics (Rogers 1995)	Provide education and feedback, adapt the innovation to improve consequences
Attitudes	Attitudes, utilities, advantage, costs, risks of the innovation	Theory of planned behavior (Ajzen 1991)	Provide education on consequences
Perceived subjective norms	Perceptions of other behavior, social, professional role, compatibility, visibility of the innovation, social comparison	Theory of planned behavior (Ajzen 1991)	Organize social influence
Beliefs about capabilities	Perceived behavioral control, self-confidence	Social cognitive theory (Bandura 1986) Theory of planned behavior (Ajzen 1991)	Provide skills training
Emotion	Satisfaction with performance, attractiveness of the innovation	Theory on motivation for learning (Newman & Peile 2002)	Provide feedback; provide education and counseling to change individual standards
3. Behavioral factors
Behavioral regulation	Coping behaviors, observational learning, central/peripheral route	Social cognitive theory (Bandura 1986) Coping Theory (Lazarus & Folkman 1984)	Provide feedback and reminders to enable self-regulation; provide education and counseling to change individual standards
Skills	Competence, behavioral capability, flexibility, divisibility, triability of the innovation	Cognitive theory on learning (Norman 2002)	Provide education to improve competency; use decision support systems
4. Interaction in professional teams
Team cognitions	Objectives, group vision, task orientation, group norms	Theory on team effectiveness (DeDreu & Weingart 2003) Theory on group decisions (Turner & Pratkanis 1998)	Change team members or decision processes
Team processes	Group composition, participation safety	Theory on team effectiveness (De Dreu & Weingart 2003) Theory on group decisions (Turner & Pratkanis 1998)	Training to change group processes
5. Structure of professional networks
Leadership and key individuals	Change agents, opinion leaders, source of the message	Theory on persuasion (Petty, Wegener & Fabrigar 1997) Theory on leadership (Yukl 1998)	Identify and involve formal and informal leaders
Social network characteristics	Range, density, multiplexity, weak ties, etc.	Social support theory (Hogan, Linden & Najarian 2002) Theory on Social comparison (Suls, Martin & Wheeler 2002) Theory on diffusion of innovations (Rogers 1995)	Involve change agents to transfer information; develop networks to create more “weak” linkages
6. Organizational structures
Specifications	Clinical protocols, benchmarking, systems perspective	Disease management systems (Hunter 2000) Theory on organizational innovativeness (Damanpour 1991)	Implement integrated care systems, e.g. chronic care model
Flexibility	Flexible delivery system, minimum specification, formalization, fragmentation, operational variety	Complex adaptive systems (Plesk & Greenhalgh 2001) Theory on organizational innovativeness (Damanpour 1991)	Redesign specific services in the organization
Leadership structure	Constancy of purpose, management in different stages, centralization, management attitudes/tenure, administrative intensity	Theory on quality management (Prajogo & Sohal 2001) Theory on organizational innovativeness (Damanpour 1991)	Recruit and train to have specific types of leaders
Specialization	Differentiation, professionalism	Theory on organizational innovativeness (Damanpour 1991)	Change the mix of professional skills in the organization
7. Organizational processes
Continuous improvement	Training of professionals, talent-developing programs, process mindedness, continuous education, concern for measurement, experimental mindset	Theory on quality management (Prajogo & Sohal 2001) Theory on organizational learning (Senge 1990)	Create teams for improvement
External communication	Customer mindedness, reactiveness, scanning imperative, complexity, external influence, suppliers as partners	Theory on quality management (Prajogo & Sohal 2001) Theory on organizational innovativeness (Damanpour 1991)	Undertake patient satisfaction activities
Internal communications	Climate of openness, generative relationships, involvement of nonmedical professionals, employee mindedness, cooperation focus, multiple advocates, ownership, cultural diversity, involvement of target group	Theory on quality management (Prajogo & Sohal 2001) Theory on organizational innovativeness (Damanpour 1991) Theory on organizational learning (Senge 1990) Theory on knowledge management (Garavelli, Gorgoglione & Scozzi 2002) Theory on organizational culture (Scott, Mannion, Davies & Marshall 2003)	Undertake care provider satisfaction activities; use ICT for transfer of information
8. Organizational resources
Technical knowledge	Competence base, organizational intelligence, creativity, knowledge information systems	Theory on organizational innovativeness (Damanpour 1991)	Change the mix of professional skills in the organization
Organizational size	Size of teams	Theory on organizational innovativeness (Damanpour 1991)	Merge/split organizations or departments
9. Societal factors
Professional development	Education and legal protection related to body of knowledge	Theory on professional development (Freidson 1970)	Revise professional roles
Priority on societal agenda	Public relations, political action	Theory on agenda building (Walters, Walters & Gray 1996)	Undertake activities to influence policy makers
10. Financial incentives
Positive incentives	Rewards, simple attractors, resources, structures for rewards, slack resources, support for innovation, provider utility function	Theory on financial reimbursement (Sonnad & Foreman 1997)	Change the provider reimbursement and patient copayment
Provider and patient financial risk sharing	Budgets, capitation, etc., supplier induced demand	Theory on financial reimbursement (Sonnad & Foreman 1997)	Change the provider reimbursement and patient copayment
Transaction costs	Cost improvement, switching costs related to innovation	Theory on contracting (Chalkley & Malcomson 1998)	Change the financial system for health care
Competition intensity	Maturity of the market	Theory on competition and innovation (Funk 2002)	Introduce market characteristics, such as financial risk and improved information for users
11. Regulations

What factors should we consider when deciding to use a single or multicomponent KT intervention?

• Early research suggested that multicomponent interventions for KT are most effective (addressed a larger number of barriers for change)
• Later research raised doubts about this…
• Not clear what constitutes a “single intervention”
• Is an outreach visit that includes instruction, motivation, planning of improvement, and practical help a “single intervention”?
• Is an intervention that combines different types of professional education (e.g., lectures, materials, and workshops) that all address lack of knowledge a “multicomponent intervention”?
• Multicomponent interventions could be more effective if they address different types of barriers for change
• The efficiency, feasibility and sustainability of multicomponent interventions needs to be evaluated

Future research

• How comprehensive and systematic does an analysis of determinants of change have to be?
• What is the added value of tailoring KT interventions?
• How should design KT programs be designed?
• What is the link between barriers for change and choice of KT interventions?
• How to best define testable hypotheses in unique and complex KT programs addressing multiple issues and stakeholders?
• How can the impact of KT interventions be sustained?
• How effective and efficient are systematic KT interventions development compared to pragmatic, simple methods for choosing interventions?
• How are different stakeholders best involved in KT intervention development?
• Continued research on the determinants of improvement in health care would also help guide the choice of KT interventions

Summary

• Choice of KT interventions remains an “art” informed by science
• Practice-based experience and creativity are important in selecting KT interventions
• Use a stepwise approach and structured methods helps take a comprehensive and balanced approach
• Research evidence on KT interventions can provide guidance, if only to show which interventions should be avoided